Observaciones de las prácticas pedagógicas

OUTCOMES OF COSMETIC SURGERY

To achieve psychological benefits, such as to improve self-confidence, body dissatisfaction and quality of life, is arguably the most important reason for individuals to undergo cosmetic surgery. This chapter presents a general overview of the current findings of psychological and psychosocial outcomes of cosmetic surgery, including the predictors and factors that may influence the surgery outcomes. The overview focuses on studies after the 1990s, given the apparent methodological flaws in the earlier studies discussed in the previous chapter. A summary of methodological limitations identified to date in the later studies is presented last.

An Overview of Cosmetic Surgery Outcomes

General overview. A number of systematic reviews have reported that cosmetic surgery patients in general showed satisfaction with the surgical result and felt better about themselves; however, the extent to which cosmetic surgery has a positive impact on various psychological domains, particularly psychological illnesses, remained less clear due to the mixed results presented across studies (e.g., Brunton et al., 2014; Castle, Honigman, & Phillips, 2002; Cook et al., 2006; Honigman, Phillips, & Castle, 2004). Below are some example studies demonstrating the mixed outcomes presented in the literature, most of which involved a sample of patients who underwent various types of cosmetic surgery including breast-related surgeries, liposuction, abdominoplasty, rhinoplasty and other facial surgeries. The findings of these studies are primarily related to the postoperative body satisfaction and self-esteem, psychopathology and quality of life of cosmetic surgery patients. A section devoted to breast augmentation outcomes follows, partly because breast augmentation is arguably the most popular procedure worldwide; and also because much attention has been placed on breast augmentation patients due to the significantly higher rates of suicide after the surgery (Sarwer, Brown, & Evans, 2007).

Body image and self-esteem. The first psychological outcome concerns the cosmetic surgery patients’ postoperative body image. Body image measures typically involved body image evaluation (i.e., overall appearance satisfaction) and body image investment (i.e., the amount of effort the individual invests in physical appearance), also known as appearance evaluation and appearance orientation respectively (Cash, 2000). In general, cosmetic surgery patients are satisfied with the surgery outcome, and show improvement in body dissatisfaction (Mulkens et al., 2012). Some studies found significant improvement in dissatisfaction towards the particular body feature altered by surgery, but the improvement in overall body satisfaction (i.e., appearance evaluation) was insignificant (e.g., Sarwer, Wadden, & Whitaker, 2002). This finding is supported by a prospective longitudinal study with data collection over a period of 13 years, where cosmetic surgery patients showed no postoperative improvement in their general appearance satisfaction (von Soest et al., 2012). Other studies found significant improvement in both specific body part and general body dissatisfaction after the surgery (Bolton, Pruzinsky, Cash, & Persing, 2003; Sarwer et al., 2005). In terms of body image investment and self-esteem, von Soest and colleagues (2009, 2011) found no change in appearance orientation and little to no improvement in self-esteem at 6-month and 5-year postoperative follow- up. These findings are consistent with and supported by numerous studies (e.g., Dowling, Jackson, & Honigman, 2013; Sarwer et al., 2005), suggesting that cosmetic surgery may have no effect on individuals’ global self-esteem, their perceived level of appearance importance and the amount of effort they invest in physical appearance due to appearance concerns. However, a few studies showed decreased body image investment (e.g., Margraf, Meyer, & Lavallee, 2013) and some showed improved self-esteem (Saariniemi et al., 2014), demonstrating the mixed findings in cosmetic surgery outcomes regarding body image and global self-esteem.

Psychopathology. Some studies showed postoperative improvements in psychological distress such as depression (Schlebusch & Mahrt, 1993), reduction in anxiety and neuroticism, and an increase in extraversion scores (Ercolani, Baldaro, Rossi, Trombini, & Trombini, 1999). Dowling and colleagues (2013) also found postoperative reduction in anxiety and depressive symptoms, as well as reduction in dysmorphic concerns with physical appearance among cosmetic surgery patients compared with their preoperative baseline measures. Findings of psychological

improvement are supported by a longitudinal study with data collection over a one- year period, where cosmetic surgery patients showed significant improvements in the areas of emotional and behavioural difficulties due to appearance concerns, as well as a reduction in depressive and anxiety symptoms compared with the control group (Moss & Harris, 2009). On the other hand, many other studies showed no significant improvement in psychological problems in cosmetic surgery patients (e.g., Bolton et al., 2003; von Soest et al., 2009), and some found no change in those with preoperative probable emotional disorders (e.g., Klassen, Jenkinson, Fitzpatrick, & Goodacre, 1996). In contrast to these findings, a prospective longitudinal population- based study found cosmetic surgery participation a significant predictor for greater increase in depressive and anxiety symptoms, eating problems, and alcohol consumption compared with the cohort sample who did not undergo cosmetic surgery (von Soest et al., 2012). The poorer mental health and higher health risk behaviours in women who have had cosmetic surgery have been previously found in a large population-based study in Australia, where women with a history of cosmetic surgery were more likely to have poorer psychological wellbeing, to smoke, drink alcohol and engage in dieting behaviours compared with the cohort sample without a history of cosmetic surgery (Schofield, Hussain, Loxton, & Miller, 2002).

More recent studies showed preliminary findings of improvement in patients with ‘mild to moderate’ BDD in terms of surgery outcome satisfaction and reduction in BDD symptoms, and suggested that cosmetic surgery may be beneficial for a selected group of BDD patients (e.g., Felix et al., 2014; see review by Bowyer, Krebs, Mataix-Cols, Veale, & Monzani, 2016). However, cosmetic surgery for patients with BDD or probable BDD is generally detrimental and the underlying symptomatology is unlikely to be addressed by the surgery (Crerand, Franklin, & Sarwer, 2006; Wilhelm, Phillips, & Steketee, 2013). In addition, some have found that the psychological improvement in mild to moderate BDD patients was of a temporary nature and the positive effect of the cosmetic surgery wore off over time (Crerand et al., 2010).

Psychosocial functioning and quality of life. Postoperative interviews revealed that cosmetic surgery patients often believe that surgery achieves not only a physical appearance change, but also a change in their psychosocial functioning and quality of life (Adams, 2010). Significant improvements in quality of life, as well as

other psychological measures, are often witnessed among patients undergoing breast reduction surgeries (e.g., Eggert, Schuss, & Edsander-Nord, 2009; Neto et al., 2008; Spector, Singh, & Karp, 2008). Excessively large breasts, also known as macromastia or breast hypertrophy, can often lead to physiological symptoms such as back or neck pain and consequently lower one’s self-reported quality of life (Brown, Hill, & Khan, 2000). For this reason, breast reduction surgery may be driven by physiological reasons on top of aesthetic reasons. It can be difficult to assess whether patients are undergoing breast reduction surgery for purely aesthetic reasons without a more in- depth interview, making generalisation of findings difficult. Some studies of cosmetic surgery outcomes do not regard breast reduction as ‘pure’ cosmetic surgery and such surgery is excluded from their research. The current study takes the same stance, where studies investigating breast reduction outcomes exclusively are not further elaborated.

Among studies that investigated the psychosocial outcomes of other cosmetic surgery exclusively or of a combination of various cosmetic surgeries, research suggested that cosmetic surgery generally results in improvement in psychosocial functioning and quality of life (Cook et al., 2006). In addition to improvement in quality of life, sexual functioning (Saariniemi et al., 2014) and health-related quality of life (Papadopulos et al., 2007) were also documented. However, a 9-month follow- up study revealed that preoperative cosmetic surgery patients were significantly more anxious compared to the general population norm largely due to lack of self- confidence; the postoperative improved quality of life found in this study were largely accounted for by (or ‘thanks to’, as the author described it) the ‘anxiety’ component, as their findings showed no improvement in other areas of psychological components that were associated with quality of life (Meningaud et al., 2003). Nevertheless, the positive outcome of quality of life is supported by a prospective longitudinal research with data collection over a period of two years, where cosmetic surgery participants showed significant improvement in quality of life most apparently in the first three months after the surgery; the improvement did not continue but was maintained throughout the second postoperative year (Sarwer et al., 2008). It might be interesting to note that in the same study, cosmetic surgery patients showed significant improvement in appearance evaluation, and no significant change in appearance orientation, self-esteem and the quality of life in relation to body image as measured by the Body Image Quality of Life Inventory (BIQLI) (Sarwer et al.,

2008). Quality of life in relation to body image refers to how the individuals’ overall body image experiences affect various aspects of their lives, such as feelings of self- worth, sexual and social relationships in their lives (Cash, Jakatdar, & Williams, 2004). The findings above may suggest that cosmetic surgery patients’ increased appearance satisfaction has minimal or no influence on how their overall body image experience affects various important domains in life and their global sense of oneself. With an expectation that body image quality of life would improve with an improvement in appearance satisfaction, Sarwer and colleagues (2008) suggested that it may be possible that body image quality of life is more closely associated with a certain type of surgery and the effect was not detected in their heterogeneous sample involving various types of cosmetic surgery. However, one could also argue that body image quality of life is likely to remained unchanged after cosmetic surgery when appearance orientation — one of the fundamental constructs of overall body image — remained unchanged in the study. In addition, note that it is not uncommon for studies of cosmetic surgery outcomes to find a significant increase in appearance evaluation, and little or no change in self-esteem (e.g., Dowling et al., 2013); Sarwar and colleagues (2008) further pointed out that self-esteem is a multifaceted construct, and may not be responsive to one specific change in psychical appearance. Together, this may suggest that appearance satisfaction may not be directly associated with one’s global self-esteem, and quality of life in relation to overall body image.

Breast augmentation outcomes. Breast augmentation is the most common cosmetic procedure in the United States and worldwide (ASAPS, 2016; ISAPS, 2016). Individual studies that involved smaller sample sizes tend to report positive outcomes among most of the patients undergoing breast augmentation with implants. For instance, a seven-month follow-up study found significant improvements in self- esteem and depression scores compared with baseline measures in a sample of 79 breast augmentation patients (Saariniemi et al., 2012). Longitudinal studies also found improvement in a number of areas when compared with baseline, such as increased satisfaction with breasts, improved psychological and sexual wellbeing (McCarthy et al., 2012); and improved psychosocial wellbeing (Alderman, Pusic, & Murphy, 2016).

However, it has been revealed by several population-based epidemiological studies that the postoperative suicide rates of breast augmentation patients are higher

compared with the general population, and compared with patients who underwent other types of cosmetic surgery (Zuckerman, Kennedy, & Terplan, 2016). For example, studies found that breast augmentation patients had higher suicide rates when compared with women of similar age and race who obtained other cosmetic surgeries during the same time period (e.g., Brinton, Lubin, Murray, Colton, & Hoover, 2006; Villeneuve et al., 2006) and compared with the national mortality statistics of women in the same age range from the same country (e.g., Lipworth et al., 2007). A population-based study also compared mastectomy (surgical removal of breast(s), commonly applied to women with breast cancer) patients with and without implants and found significant higher rates of death due to suicide in women with implants compared with women without (Le et al., 2005). Further, a recent review study conducted additional statistical analyses and compared postmenopausal women with and without implants based on Rubin and colleagues' (2010) study (Zuckerman et al., 2016). They found that postmenopausal women with implants were 12 times more likely to commit suicide compared with those without implants (Zuckerman et al., 2016).

Among epidemiological studies that also assessed mental health and quality of life, a study found that Danish women who underwent breast augmentation had higher rates of suicide compared with the general female population and higher rates of psychiatric hospital admission compared with other cosmetic surgery patients (Jacobsen et al., 2004). Jacobsen and colleagues (2004) pointed out that this finding is likely confounded by the fact that government funded breast augmentation procedures require psychological evaluation in some public hospitals during the timeframe of data collection, which may create an incentive for women to seek psychiatric care before the surgery. Another study found breast augmentation patients had overall poorer postoperative emotional and psychosocial wellbeing (Rubin et al., 2010). This study, however, lacked a preoperative assessment, making it impossible to identify whether the poor psychosocial and emotional functioning predated breast augmentation. Prospective two-year follow-up studies carried out by implant manufacturers analysing changes in several psychological and psychosocial domains in women with breast augmentation were submitted to the United States Food and Drug Administration (The United States Food and Drug Administration [FDA], 2005a, 2005b). The first study showed no significant change in global self-esteem and social functioning, and mental health was significantly poorer for breast

augmentation patients at two-year follow-ups compared with the baseline measures, although the baseline measures were reportedly higher than in the general population (FDA, 2005a). The second study showed no significant change in the individuals’ feeling of self-worth and self-image, significant decreases in mental health and social functioning, and significant increases in global self-esteem (FDA, 2005b). Together, it appears difficult to determine the pre- and postoperative psychological wellbeing of breast augmentation patients given the mixed results and methodological shortcomings of the studies.

Several possible explanations for the potential association between breast augmentation and suicide were hypothesised in review articles, including preoperative psychopathology and psychological wellbeing, unrealistic expectations of the surgery, postoperative complications, and increased risk of suicide due to implants; however, population-based epidemiological studies to date either do not support or provide insufficient evidence for the hypothesised explanations (Sarwer et al., 2007; Zuckerman et al., 2016). This led several review authors tentatively to conclude that evidence to date suggests breast augmentation with implants may have a negative impact on mental health (Zuckerman et al., 2016) and there appears to be a relationship between breast implant and suicide, however, the nature of such a relationship is unknown (Sarwer et al., 2007).

Predictors of cosmetic surgery outcomes. A recent review article identified two ‘moderate to high quality’ systematic reviews from the review articles in the literature that examined predictors of postoperative psychological outcomes (Brunton et al., 2014). Based on these higher quality reviews, Brunton and colleagues (2014) briefly suggested that gender, relationship problems, and unrealistic expectations towards cosmetic surgery may influence the postoperative psychological outcomes of cosmetic surgery patients. In order to be more specific, some relevant findings of the ‘moderate to high quality’ reviews are discussed below.

In Cook and colleagues' (2006) systematic review of cosmetic surgery outcomes, they identified a potential association between gender and postoperative outcomes where males may show less postoperative improvement compared with females. They also tentatively showed that cosmetic surgery may be beneficial for patients with more severe preoperative psychological distress, such as severe depression. However, Cook and colleagues (2006) pointed out that only a few studies

examined such an association between preoperative psychopathology and surgery outcomes, and most of the improvements reported in the findings did not reach statistical significance, with some possibly confounded by other postoperative factors, such as possible psychological support after the surgery, which was not reported in the studies. This results in a conclusion that there is not enough evidence in the literature to suggest an association between preoperative psychopathology and postoperative cosmetic surgery outcomes (Cook et al., 2006).

In Honigman and colleagues' (2004) review, they examined the potential predictors of poor psychological and psychosocial outcomes among 14 individual studies that addressed such associations. Demographic factors such as being male or of a younger age may be associated with poorer surgery outcomes. In contrast to the review above, psychological factors such as patients with a history of depression or anxiety, BDD, or personality disorders are likely to predict negative postoperative outcomes. Another predictor concerns the reasons for and expectations about the cosmetic surgery. Reasons involving relationship problems, such as patients who believe cosmetic surgery can save a relationship, or they underwent cosmetic surgery despite disagreement between partners, could lead to unfavourable psychological and psychosocial outcomes. Unrealistic expectation towards the surgery was also considered an important predictor for poorer outcomes. However, Honigman and colleagues (2004) pointed out that some of the reviewed studies simply used clinical impression, and none carried out a rigorous statistical analysis for these predictors, where the presented summary of predictors is based on the congruence of variables that appear to associate with poor psychological and psychosocial outcomes after cosmetic surgery.

Based on the apparent methodological limitations in the reviewed studies, the authors concluded that there is very little information regarding indications and contraindications for cosmetic surgery (Cook et al., 2006), and cosmetic surgeons must be cautious when working with patients presenting with the relevant characteristics (Honigman et al., 2004). These systematic review articles, albeit identified as higher quality reviews, reviewed individual studies carried out before 2004 and the findings of more recent studies were excluded.

Findings to date support an association between patients with BDD and poor psychological and psychosocial postoperative results (Bowyer et al., 2016), as addressed earlier in this chapter. Patients with BDD are likely to seek multiple

cosmetic surgeries in an attempt to fix the perceived physical defects, and are more likely to remain preoccupied and dissatisfied with the body feature altered by surgery (Phillips, 2009). Among the few who are satisfied with the body part that underwent surgery, patients with BDD are likely to shift their preoccupation and dissatisfaction to another body part and may seek additional cosmetic surgery to address new appearance concerns (Bowyer et al., 2016; Phillips, 2009). Cosmetic surgery does not appear to address the underlying symptomatology of BDD and is associated with possible exacerbation of the symptoms and the already impaired functioning (Bowyer et al., 2016; Honigman et al., 2004; Phillips, 2009).

A more recent review also supports an association between unrealistic expectations and poor psychological outcomes of facial cosmetic surgery (Herruer, Prins, van Heerbeek, Verhage-Damen, & Ingels, 2015), and deemed it important in the current practice of cosmetic surgery to assess and screen patients for unrealistic expectations before they undergo cosmetic surgery (Paraskeva, Clarke, & Rumsey, 2014). Unrealistic expectations are often used to describe dissatisfaction towards the result after surgery (Herruer et al., 2015). The construct definition for ‘unrealistic expectations’ across studies is considerably vague as it could involve expectations regarding the physical, psychological, and psychosocial outcomes. Wright and Wright (1975) suggested that patients who desire exact alteration from cosmetic surgery could be one of the contraindications for the surgery. Herruer and colleagues